Kelley Walsh Angie Standiford Donna Sanders

Hopkinsville Middle School

______

______

Kelley Walsh Angie Standiford Donna Sanders

Guidance Counselor Guidance Secretary Guidance Counselor

434 Koffman Drive

Hopkinsville, Kentucky 42240

Phone- 270-887-7132 Fax- 270-887-2748

I request ______

School, Agency or Institution

______

Street Address

______

City State Zip Phone or Fax number

to release and send to Hopkinsville Middle School the records of

______

Name of student Birthdate Grade

A.  Regular cumulative records to include:

X Report card grades including grades in progress

X Attendance information X Health Records to include:

X Standardized test scores Immunization records

X Discipline records Physical examination

X Writing Portfolio Birth Certificate

B.  Special Education records to include:

X Conference summaries/minutes X Behavioral Checklists

X Current IEP X Observations

X 2 latest psychological evaluations X Speech records

Signature of Parent/Guardian Relationship Date

Signature of School Official Position Date

If any of this information is available from another department such as Central Office or Psychological Services, please forward this request to that office.

Federal Law (34 CFR § 99.31): In accordance with FERPA, parental permission is no longer required when records are sent to another educational agency.

Date ______

KRS 158.155 requires a parent or guardian of a child to prove the following information in the form of a sworn statement before a child is admitted to public schools in Kentucky.

In compliance with that requirement, I swear or affirm that ______(student’s name)

1.  _____ was found guilty of a violation of state law or school regulations related to

weapons, alcohol, drugs, homicide, or assault (including physical and sexual assault).

If yes, when did this occur? ______

Where ______

2.  _____ was expelled from ______school for any

violations of school rules.

If yes, when was your child expelled? ______

When would your child be allowed to return to that school system? ______

3.  _____ was referred for expulsion but left the school prior to being expelled.

If yes, what school? ______

When? ______

4.  _____ was attending an alternative school prior to moving to this school.

If yes, what school? ______

5.  _____ was referred to an alternative school, but left prior to enrolling.

6.  _____ none of the above applies to my child.

Giving false information violates state law.

If 1-5 pertains to your child, please give details: ______

Signature of Parent/Guardian